EVAN FREDERICKSON LECTURE
THE DEVELOPMENT OF RESEARCH IN ANESTHESIOLOGY
BY E.M. PAPPER, M.D.
It is a special honor and privilege for me to give the Evan
Frederickson Lecture for 1987 on a subject dear to his heart
i.e. the development of research in anesthesiology. He not only
was an able research scientist, but he had widespread
influence in encouraging its group, e.g. A.S.A. Committee on
Research.
Evan Frederickson was a cherished friend, an individual of
gracious personality coupled with an appropriately hard headed
view of research in our field of anesthesiology. He will be sorely
missed.
The treatment of the subject chosen for this Lecture – The
Development of Research in Anesthesiology could easily take many
different directions. It seems to me wise, and perhaps even
necessary, to present to you a culturally oriented story, part
history, part observation, part autobiography, and part objective
fact. This presentation is an analysis of one person's point of
view about the nature of research in anesthesiology together with
some of its principal architects, its problems, and some thoughts
about its directions.
The period of discovery of anesthesiology and anesthetic agents
is an uniquely American contribution to the welfare of humanity. I
shall attempt to make some observations on the sociological and
environmental aspects of that discovery period without in any way
attempting to engage in the controversy as to who did what first.
I recognize this could be a dangerous stance to take in Georgia, but
as you shall see we will deal with the state of mind of that
period and why the discovery of anesthesia was part of the events
in the minds of western man at that time.
The era of ferment throughout the western world was the
necessary setting for the discovery of anesthesia. Whether one
thinks of the discovery of anesthesia as 1842 or 1846, or perhaps
some other date, the “discovery” took place shortly before three
other unique events in western history occurred. 1859 was the
remarkable coincidence and turning point in modern western
history which, in my view, has something to do with the discovery
process in our field as well as the ferment of curiosity in other
fields. This was the year that Darwin's "Origins of the Species" was
published as was Karl Marx's "Critique of Political Economy" and
Richard Wagner's opera Tristan and Isolde was first presented.
(1) At this juncture of my investigations I cannot point out
detailed relevances more definitively than these almost
simultaneous and remarkable flowerings in western culture were not
a coincidence. My belief is that one will find that the Romantic
Period in Europe and the United States made possible the
simultaneous exuberance of so much of curiosity, scientific
thought and the mechanical materialism which would come soon
thereafter.
Prior to these events, the geniuses of the Romantic Period,
especially in Great Britain, contributed in an important way to
the combination of intellectual strength and the energies of
emotion which overlap and reinforce each other. For instance,
prior to the 'discovery' the names of the writers Beddoes famous for
his Pneumatic Institute in Bristol and of the great
autobiographer Sir Humphrey Davy, for his discovery of the
anesthetic properties of nitrous oxide in the earlier part of
the 19th century are examples of this curiosity and ferment. What
is not generally appreciated however, by most of us is that
Beddoes, Davy, Keats, Shelley and others of the Romantic Period
viewed individual energy and individual experience as being of
paramount importance in cultural development. Nothing was out of
bounds for them to study and to comment upon. There were great
essays, there were poems, there is, in the case of Sir Humphrey
Davy, a marvelous seven volume autobiography of which so many of
the things in the world of the mind and the emotions of this period
are considered.
After this ferment of great activity in the case of
anesthesia, unlike that of other important events, there follows
a "motionless" period of some eighty years. The quiescence in
anesthesia research and anesthesia practice is a strange one.
There was no great thrust of intellectual activity in
anesthesiology after the discovery period until the era between
the two world wars.
The basis for the modern aspects of the development of
research in this country started with the work of Ralph Waters
of Wisconsin, of E.A. Rovenstine, first at Wisconsin and then
New York, of Chauncey Leake at Wisconsin and then San Francisco
and others who began the scientific investigation of the
anesthetic process. The pioneering work of Waters and his
disciples at Wisconsin between the two world wars enlisted the
interest and activity of basic scientists whose work was
primarily in physiology and pharmacology. Efforts were with such
basic scientists as Professors Walter Meek and Maurice Seavers
to understand better the effects of anesthetic agents upon the
various systems of the body. Their particular interest was in
the actions of anesthesia upon the circulation, and respiration,
and just prior to World War II, other organ systems began to
attract attention also. Anesthetic problems related to shock,
trauma, body water, and kidney function were studied. A major
accomplishment, since research is done by hard working, well
prepared people was the establishment of the unique educational
program in clinical care and research at the University of
Wisconsin beginning in 1928, and spreading to other
institutions of that period, e.g. New York University, the
University of Pennsylvania, Columbia University, Tulane, Iowa,
Harvard and others. Parallel with, but not part of this
development was the extraordinary recognition for its time of
the importance of physiological change during anesthesia by
Henry K. Beecher, at the Massachusetts General Hospital, who
brought the benefits and the thinking of European, especially
Scandinavian thought to the United States in this area of
science.
Similar developments were occurring at Oxford under the
leadership of Dr. Robert Macintosh, later Sir Robert Macintosh,
whose early students included such distinguished investigators
as William Mushin, and Edgar Pask. Their interests were the
practical application of science to clinical practice and
included also the development of new apparatus and new
attitudes toward the management of vital systems, especially
respiration and circulation. There developed before War II a
serious interest in other forms of anesthesia e.g. intravenous,
regional and spinal anesthesia, as well as the recognition of
the need for the development of anesthetic agents that were an
improvement over ether and chloroform. Serendipidy played no
small part in the discoveries of such agents as cyclopropane, and
ethylene. These studies opened the path to the recognition that
newer and better drugs were possible of achievement.
The advent of World War II, provided an important large
scale, although tragic opportunity for young surgeons, internists,
and the small cadre of anesthesiologists then available to
understand both the importance of the contributions of clinical
anesthesia to human safety during surgical procedures and major
injury, as well as the need to improve the knowledge derived from
research for these purposes. In addition, an unnoticed
development at the time took place which was to have a major effect
upon research in anesthesiology as well as the establishment of
directions for new and sustained activity that would occur after
World War II. In the attempt to develop the atomic bomb, one of the
problems that was encountered was the need to control the rate of
reaction of nuclear fission, and to provide stabilized compounds
that would essentially be unreactive with respect to these
important physical and chemical processes. The distinguished
chemist Schmidt, at the University of Illinois found that
halogenation of certain fluorinated compounds was crucial to the
control of the reactions important in nuclear fission. This
concept of halogenation was to be rediscovered and applied by the
Spanish-British pharmacologist Raventos, in the immediate post-war
period for the development of a whole new set of halogenated,
especially fluorinated anesthetic agents, which would have a
massive influence upon the change of anesthetic practice.
Halothane was the first practical product. In some respects,
therefore if one takes a cultural or perhaps even a moralistic
view of the evils of a major world war, and atomic weaponry, one
can believe that some good can come out evil. The halogenated
anesthetic agents were in large part made possible by research
in the development of the atomic bomb.
After all the events that took place during World War II,
in the immediate post war period research in anesthesiology took
place in a major way. Anesthesiologists joined the family of
clinical scientists in a more systematic and intellectual
examination of the purposes of research. The day of tinkering in a
workshop or what may have passed for a makeshift laboratory was at
an end. Even though the purposes of research were not clearly
stated they were certainly acted out by the post-war
participants. It became quite obvious that there were a number
of purposes of research for someone interested in a clinical
field like anesthesiology.
The first of these purposes was curiosity for its own sake.
How do things work? The debate about the value of the
satisfaction of individual curiosity is one that derives also
from the period of discovery of the romantic era. It is of course
still debated, and understandably so. Is it more important to
plan research for potential practical purposes, which shall be
discussed in a moment, or is the satisfaction of individual
curiosity for its own sake a valid end in itself?
A second purpose of research was in, our case, the support of a
rapidly evolving clinical practice with the newer knowledge that
could be obtained only by research. It was no longer adequate to
collect several hundred cases of this or that. It became necessary
to pose appropriate questions derived from the problems presented
in the clinic, and to turn to either the clinic or the laboratory
or both for the finding of answers to these questions in a precise,
methodical, and systematic manner that would permit others to share
in this acquisition of new knowledge and perhaps even more
importantly to reproduce research findings and to extend knowledge
further.
A third important purpose of research for a clinician is
concerned with the acquisition of methods of improved observation,
keeping up with the fruits of research and making as rapid an
application as is prudent to patient care. Finally the education
of the future practitioner is a joint effort by research workers
and clinical practitioners.
It is now necessary to turn our attention to some aspects of
the substance of research. The period between the wars saw the
development of the newer inhalant anesthetic agents cyclopropane,
and ethylene, largely the result of the work of Dr. Waters, and the
Wisconsin School. The introduction of the important series of non-
volatile anesthetic agents the first of which was thiopental,
occurred in 1935 at the Mayo Clinic under the direction of John S.
Lundy, and his associates there. In the decade following the war,
the halogenated inhalant anesthetic agents were developed as was
the continuation of the practical development of muscle relaxants.
The early work in the field of muscle relaxants was unfortunately
suspended because of war requirements, else progress probably
would have occurred earlier and sooner. Most important was the
clinical introduction of muscle relaxants in 1942 by Harold
Griffith, and Enid Johnson in Montreal. It is worth a few moments
of description of this study because it illustrates one of the
important ways of thinking about research. Also, a little anecdote
will do you no great harm. This is not the place, nor is there
opportunity to describe the history of muscle relaxant drugs, but
suffice it to say at the time just before the outbreak of World War
II the Squibb Company had developed an impure version of curare, and
made it clinically available to a group of clinicians interested
in preventing injury from induced convulsive seizures for the
treatment of depression and mental illnesses. The incidence of
fractures and other similar complications of injury was sharply
reduced. The concept of applying muscle relaxants to enhancing the
effects of improved surgical operating conditions was discussed
at great length in a rather limited circle. Dr. Lewis Wright, who
was an anesthesiologist working for the Squibb Company at the
time was a very highly respected individual in anesthesiological
circles and it was he who offered this curare substance, then
known as intocostrin, to several groups for study. There were, at
the time, no ethics committees in hospitals to determine the
morality of trying new drugs on patients, and the sole criterion
of ethical behavior was that an investigator was willing to
have it used on himself! Wright provided some of this relatively
scarce material to Dr. Stuart Cullen, one of the important
personalities in the support of research in anesthesiology, then
at the University of Iowa for study. Cullen elected to study this
material in the dog, and the results were so unimpressive that he
and his associates felt that it would have relatively little
value. Wright also gave some of this material to E.A. Rovenstine
who turned it over to me for study. I was at the time a freshly
minted physiologist in the distinguished Department of
Physiology led by Homer Smith at New York University. I had also
completed my residency in anesthesiology with Rovenstine at New
York University. It was Rovenstine's established procedure to use
new adjuvant drugs during general anesthesia with ether as the
anesthetic agent. Lewis Wright outlined what we should do with
the crude preparation of curare, although he took a guarded
position about its use during ether anesthesia - even though the
Squibb Company had a large market share of the sale of ether
challenged only by the Mallinckrodt Company. A first and then a
second patient were selected for relatively minor intra-abdominal
surgery - as I recollect for appendectomy, but of this I am not
certain - so that relaxation could be observed during the
allegedly safe conduct of ether anesthesia. Since there are so many
people in this audience who may never have seen ether anesthesia
I should say that it turned out, with later knowledge that ether
and curare were in a major way mutually synergistic! This simple
fact was not known at the time. However, controlled respiration
was known. The long and short of this experience was that each
patient remained apneic for several hours after the end of
anesthesia, and the surgeons were singularly unimpressed by the
post-operative consequences as were we, even though they were much
impressed with the efficacy of the relaxation observed! I was
semi-petrified, and learned more in those two days about better
preparation for a clinical experiment, as well as patience
to deal with the complications of an anesthetic process,
especially apnea, which was a much more frightening experience
then, than it is today when all of you deliberately use apnea as
part of anesthetic management.
My own conclusion was that this muscle relaxant was much too
dangerous for clinical use, but Wright persisted and suggested
that we should do some laboratory experiments after our two
clinical fiascos.
Next comes a curious story in unfortunate and negative
serendipity. The favorite laboratory animal Homer Smith's Department
used for study because of its value in renal function experiments
was the cat. Again without knowing very much of the influence of
these substances on laboratory animals the cat was selected, and a
small but substantial series of cats died of severe asthmatic
attacks, and asphyxia from the use of this material. I decided
that this muscle relaxant was too dangerous in man, and lethal in
laboratory animals. Again one sees the result of inexperience and
unpreparedness. The basic fact that the drug was extremely active was
ignored in the face of all of the troubles that we encountered and
methods to salvage its major effect on muscle relaxation were
ignored in the fright of complications and undesired side effects.
Much to Dr. Wright's credit he persisted and brought the
substance to Harold Griffith who used it on patients during
cylopropane anesthesia. The lack of adequate muscle relaxation
during cyclopropane, which most of you have also never seen
used, was more than adequately overcome by the muscle relaxant.
Griffith and Johnson published their classic paper on the use
of muscle relaxants in 1942 and were duly and correctly
recognized for their contribution in introducing this way of
dealing with, at that time, a major unsolved problem in
anesthesia. I have often pondered what might have happened if
either Griffith or Johnson had not happened by sheer chance to
have used curare with cyclopropane. We might have had a long
delay in the development of this important addition to
anesthetic practice or perhaps it might have been diverted,
distorted or even killed. In this instance their lack of
experience of scientific methodology, and the scientific habit
of thought proved to be an advantage. However, it is to their
great credit that they were able to make the correct
observations even though the approach was one due to chance.
Today I think our approaches to new drug study are so much more
intelligent and more sophisticated that these kinds of events
would not be so colorful nor would I be able to tell a story such
as this to this or any other audience.
There were many other important drug developments including
the halogenated series of anesthetic agents. These agents have
turned out so well, especially the most recent of them, that
some observers believe that the ultimate has been reached in the
development of new anesthetic drugs by inhalation. Just on the
basis of intuition and experience I have to reject that
conclusion since the notion in science and in medicine that things
can improve no further is often rudely shattered by a major new
and scintillating development. When Lord Kelvin said that there
was nothing new to learn in physics, along came Planck, Bohr, and
Einstein! Another major development has been the need to
understand how anesthetic drugs and adjuvant substances affect
the body, and conversely how the body affects the drugs. The
first of these major developments is known as pharmacodynamics and
the second of them, beginning with the humble name of uptake and
distribution and replaced by the Greek derived name of
pharmacokinetics was the result. I would be both presumptuous and
foolhardy to discuss much further these developments with this
audience since members of this Department led by Dr. Carl Hug have
made such major contributions to this field.
This area of research began in an important way with the work
of John Severinghaus at Iowa in the early 1950s to study the
uptake and distribution of nitrous oxide. Severinghaus made a
direct clinical application of a scientific study for another
purpose in which Kety and Schmidt at the University of
Pennsylvania developed an uptake analysis for nitrous oxide for
the purposes of measuring cerebral blood flow by the Fick
principle. This is a brilliant application to clinical
anesthetic science and practice of a concept used in fundamental
science for an entirely different purpose.
With the almost tumultuous gathering of information about how
anesthetic drugs behave and influence body function it was
necessary to develop methods of observing these effects. These
devices ranging from simple observation of pulse and blood
pressure to the most sophisticated computer driven analyses are
collectively known as monitoring. The technology to make all of
these things possible was accompanied by a vast improvement in
vaporizers for inhalant anesthetics, ventilators, devices for
the monitoring of the effects of muscle relaxants and for the study
of the influence upon various organ systems including the brain.
Physicists, engineers, chemists joined forces with
anesthesiologists to support these developments.
We must now consider how to support research which is crucial
and important for the continuation of this vibrant activity in
our speciality. There are two basic axioms. One had to educate
individuals who would be dedicated to research and who had to
learn the methods of research, and even more important the method of
thinking about research problems and developing approaches to
their solution. A second aspect of the support of research had to
be the provision of an appropriate state of the art and science
environment, including intellectual and physical opportunities
as well as the instruments and equipment needed to carry out
research. All of this meant the assumption that there were
important and worthwhile questions to be answered in
anesthesiology, and that the fruits of these answers could be
applied to the better, more comfortable and safer care of
patients. It all added up to money. How was money to be found to
develop the education of the clinical scientist in
anesthesiology, support the basic science research needed, and
insure an opportunity for an unknown future, but one that had
great promise?
These questions were discussed among the then leadership of
the field in anesthesiology beginning a few years after World War
II, and were crystallized somewhat in the early 1950's. The
Association of University Anesthetists was established in 1953
(there are some that argue it was 1952) as a means of exchanging
scientific information and of encouraging the education and
training of young people in research in our field. This
development required no money except the support of travel.
How then was financial support to be to be achieved?
There was at the time both the capability and interest in a
relatively small number of academic departments of anesthesiology
to send their more promising research oriented young people to
basic science departments for a year or two of exposure and
education in scientific thinking and scientific research. The
basic science departments were very receptive in general in
these institutions and the results of these tentative
experiments in the development of young people were obviously
impressive and yet limited, since the institutions were few in
number and the basic science departments could only help so much.
University financial support both in state universities and
private universities was limited for practical and obvious
reasons.
The thinking among a small number of the leaders was
consciously directed to an attempt to develop major financial
support for the rapid growth and development of scientific
research in anesthesiology. There are only a limited number of
obvious sources for financial support and all were used to varying
degrees. In some of the academic departments opportunities arose
because of the cultivation by senior members in those departments
of wealthy patients who became interested in supporting the
development of research in anesthesiology. There are three examples
that are worth bringing to your attention of this approach to
support which I think still has merit and is being largely ignored
today. Significant support was given to the distinguished
Department of Anesthesiology under the leadership of Dr. Robert
Dripps in this fashion because of Dr. Dripps' personal
relationship with Mr. McNeil, a wealthy individual who owned a
large pharmaceutical company now merged with Johnson and Johnson.
Dripps took medical care of members of the McNeil family including
not only their anesthesia, but providing and seeking
specialists and physicians for them as they were needed. He also
spent many Sundays with Mr. McNeil to keep this friendship going.
I am not implying any ulterior motive since the friendship
between Dr. Dripps and Mr. McNeil was a warm and close one, but it
did result in an important establishment of support on both a
short and long term basis for the important Department of
Anesthesia at Pennsylvania.
Dr. M.T. Jenkins had a similar relationship to an oil
wealthy family known as McDermott, who provided an Endowed Chair at
the Southwestern Medical School of the University of Texas in
anesthesiology as well as other support for research in that
department. The Columbia Department which I was privileged to lead
at that time had a similar opportunity with a wealthy patient,
Mr. Charles B. Wrightsman, whose interest in anesthesiology came
from early bad experiences as a child anesthetized for
tonsillectomy in the then Oklahoma territory. Mr. Wrightsman was an
unusually brilliant, as well as wealthy man, and chose to support
both medical activities and the fine arts in a substantial way.
As a small digression, there are sixteen Wrightsman rooms in the
Metropolitan Museum of Art in New York City containing major
works of art that he and Mrs. Wrightsman gave to that museum. They
were generous also in the support of other medical specialties
which were of interest to the family. All of it derived from
patient care by some physician or surgeon. I was able to solve the
problem of pleasant and safe induction of anesthesia for Mr.
Wrightsman by the simple device of rendering him unconscious by
a safe and guarded injection of thiopental in his room before
operation and took care of him myself in the post-operative
period before the days of intensive care and in the early period
of recovery room care. He became much interested in anesthesiology
as a result of this experience, and provided a major financial
impetus to the early support of the Columbia Department from his
own substantial resources. There are many stories that I guess
should be told, but one naive experience on my part might
illustrate the period of my youthful inexperience. When Charles
Wrightsman was recovering from his surgery, he wanted to help our
department, and did so in many ways which are not necessary to
describe here today, but one small anecdote might be of interest.
One morning on about the fifth or sixth post-operative day he
asked me what I needed to support research in the Columbia
Department. He suggested I should think carefully about it, and
produce a realistic suggestion of the amount of financial support
needed. This I did and suggested to him what to me was the very
large sum of twenty-five thousand dollars! He roared with
laughter at my inexperience and wrote out a check for twenty-five
thousand dollars on the spot, and said that when I learned more he
would help support the fruits of that learning. It subsequently
turned into several million dollars before that relationship
was completed with his unfortunate illness and subsequent death
some years later. My relationship with Mrs. Wrightsman and all of
the family and friends still continues to this day as a very
happy experience for me in "remembrance of things past".
I think I am suggesting that our leadership today might
consider as part of their appropriate missions the
identification and cultivation of wealthy patients for private
support of the work of their colleagues. This means a serious
attention to the only conduct that is understood by potentially
grateful patients and that is the impression upon them either
from their own experiences or observations or both of the great
value of anesthesiology. I respectfully suggest that a repetition
of these three examples is possible and desirable in clinical
activity of Departmental Chairman and senior people in the
departments today as part of the provision of research support.
The work is hard but very pleasant.
As the result of another experience with wealthy patients I
had the privilege of being the anesthesiologist for Mr. Albert
Lasker whose widow, Mary W. Lasker is the great lady who has done so
much to support bio-medical research in all fields in this
country both from her private resources, those of her friends,
but especially the great influence and favorable one that she has
had upon the National Institutes of Health, in providing
increased support for medical research in this country. Albert
Lasker was a business genius, who literally started the
advertising industry. Mr. Lasker's interest in medical research
and his financial acumen were great. Mr. Lasker felt that his
private contributions and those of his friends would be grossly
insufficient compared to funds from our collective society in
the form of government support. He was important in the
establishment of the National Institutes of Health, and its
development as well as in the private sector in the form of the
American Heart Association and the American Cancer Society. In
essence he told Mary Lasker "go to the government, because that's
where the money is!"
After my opportunity to get to know Mr. and Mrs. Lasker from
having taken care of him, she asked me about the needs for support
in anesthesiology, and gave me information about his views of
seeking government support. By that time a vast development of
N.I.H. was underway, and the concept of the appropriateness of
government support of research had become acceptable and had
already taken place in other fields. To say that my inexperience
of NIH and its activities was huge is a gross understatement. The
same was true of my colleagues at other institutions. Through
Mrs. Lasker's help we were able to achieve some presence on some
of the N.I.H. study sections, and membership on several of the
councils which are the important decision groups at N.I.H. All
this help began to bring our needs to the attention of government
and to scientists everywhere. However, more had to be done in an
organized fashion.
By the strangest of coincidences the possibility of major
support appeared almost unexpectedly. Dr. Fred Stone, a
brilliant N.I.H. executive, felt it was time to establish the
institute now known as the National Institute of General
Medical Sciences for the support of research in the basic
sciences that did not have the sex appeal of the categorical
diseases like cancer or heart disease. Like any good executive,
he was perfectly willing to make trades and encouraged the
development of the clinical scientist idea. He and his
associates, in addition to wanting this new Institute
established, proposed the developed of research career development
awards, and research career awards to insure the presence of young
people in scientific research in all fields and to pay
particular stress to those fields which were greatly
underdeveloped. Another coincidence that led to the story that I
shall tell you shortly was the fact that the Director of the
National Institutes of Health at that time was Dr. James A.
Shannon, whose graduate student I had been in Homer Smith’s
Department of Physiology at New York University.
As the result of much discussion and many meetings it was
decided that the best way to push these programs of the
development of biomedical scientists as well as the sustenance of
under supported specialties such as anesthesiology, would be to
have one of us in a leadership position at the time spend a year
or so in Washington to help the N.I.H. professionals get these
programs on their feet and on their way. Fred Stone was close to
the then Dean at the College of Physicians and Surgeons at Columbia
University, Dr. H. Houston Merritt, and also knew me. He also
learned about the relationship with the Lasker Family that I had
developed and persuaded Dr. Merritt to assign me to Washington on
the only sabbatical leave that I have ever taken. Please do not
interpret this statement as criticism of sabbatical leaves, I am
just describing a fact. Those also were more authoritarian days,
and when the Dean or the Chairman asked or told you to do something
you did it. Again, I do not support the merit of such behavior
but simply describe it. So off I went to Washington to work in the
National Institute of General Medical Sciences to help develop
research support for anesthesiology, surgery, radiology, pathology,
and pharmacology. Since I was a fervent Democrat in those days, it
was not too difficult with the help of Mary Lasker to establish
appropriate contacts with the power structure in health affairs
in both the Senate and the House of Representatives. As the young
people of today might say "we were on a ‘roll’"! Fred Stone
designed the N.I.H. character of the programs, Bob Dripps spoke to
the Republican Members of the Congressional Committees, and I
dealt with the Democrats. Once our programs were in shape and
organized we were going to have earmarked money for anesthesiology
as well as for the other four fields for which I was responsible.
A program would be developed within the National Institute of
General Medical Sciences, and I was given the responsibility of
bringing it to Jim Shannon the Director of N.I.H. for approval.
Since I worked for him for several years and he knew me well, he
was willing to listen. I still have a visual and happy memory of
talking with that wonderful person with his feet on the desk (a
practice I disapprove of in others), a bow tie of vibrant color
(a taste that I do not share), and fascinating discussions
that took only a few visits to have his approval. Once his
approval was obtained it was then necessary to get us into the
N.I.H. budget via testimony before the appropriate
congressional committees. Mrs. Lasker through employees of the
Lasker Foundation and others trained me and others of our
contemporaries at the time in how to testify before Congressional
Committees. This was not as difficult as it may seem since almost
always there was a dinner party where we dined together in
very small groups previously with the very people who were to
listen to the testimony due to Mrs. Lasker's help. Our needs
were substantial, and our potential was very great. Our
opportunity had come, and I feel to be the privileged small
vessel who carried the jugs around the various places in
Washington to get it done. The result was a substantial
appropriation for anesthesia research, the establishment of
anesthetic research programs, project grants, the establishment
of anesthesia centers for research, provision of research career
awards, of which John Severinghaus was the first recipient in
Anesthesiology and Research Career Development Awards to many
younger people, some of whom are today's leaders. There were
opponents, of course, to feeding at the federal trough. However,
they were among the first applicants for the grant support that
occurred and pragmatism triumphed over principle as it usually
does!
I am told that N.I.H. support for anesthesia has dwindled,
and it is no longer viewed as a high priority item in the
national scene. The present leadership needs to determine what it
wishes to do other than complain. Complaint and criticism have
rarely resulted in the mounting of programs, but hard work, and
willingness to produce may be of help. I have no practical
suggestions to make, except to urge that a renewed effort be made
to demonstrate once again the importance of research in
anesthesiology, and to pursue it with vigor.
There were other Federal Agencies that participated. The
Department of the Army was a strong supporter of research at
Harvard and especially at the Massachusetts General Hospital under
the important research leadership of Harry Beecher. The government
is still where most of the money is.
Our next turn was to industry as a source of support. There
are now arrangements at several institutions of major support
sources by industry for research in various fields. Some of them
are institutional, some of them are fairly specific. I think our
present leadership needs to get more involved with this
potential source of support for broad research, and less
involved in the minor small grants for the study of a specific
drug. The most successful of these relationships of which I am
aware are the Hoechst support at the Harvard Medical School and the
Mallinckrodt support at the Massachusetts General Hospital. I am
sure there are others, and even more can be established.
Finally some decision needs to be made about priorities in
terms of the use of disposable funds.
Academic departments in many institutions have established
relatively large sources of income from private practice care by
the members of their faculties. Some of these funds need to be used
for the support of research. I am in no position to evaluate how
valuable this source of income is for the support of research, but
it now is obviously insufficient for the problems which need to be
tackled. One note of criticism with regard to priorities and
attitudes, I feel, that I must bring to the attention of this
audience. I am not persuaded that an academic anesthesiologist can
expect the income of a private practicing clinician, and the
simultaneous opportunity to be supported for full time research.
This particular problem needs to be addressed, and in my opinion
needs to take the direction of some reduction of personal income
for the support of research from private practice income sources.
I realize that this matter is highly controversial but it needs
to be resolved. Private practice income is one of the places the
money is, and people have to make up their minds how to use it. You
really can't have the practitioner's money and life style and
also do major research. Each provides different personal
satisfactions.
A final word on research support is necessary. I view with
very great happiness the increased number of established endowed
chairs in anesthesiology, named lectures in anesthesiology of which
this is an important one, and similar types of striving for
private sector support. I would encourage all academic departments
to work hard for the establishment of more endowed chairs to
provide disposal income which can be, if the priorities are right,
used for research support.
There is an important remaining challenge in research. The
mechanism of anesthetic action is still unknown. Much important
work has been done by investigators in several institutions to
attempt to break into this area of ignorance. The quest must be
pressed on vigorously because a real understanding of the
mechanism of anesthesia can lead to a totally different clinical
practice for the future as well as the direction of new research
activities. To my way of thinking without in any way wanting to
minimize the importance of present studies in other areas, this is
the major challenge for the future and is of the utmost importance.
The solution of the problem of the mechanism of anesthetic action
relates to the understanding of consciousness and the
understanding of consciousness relates to the understanding of
life itself. It is hard for me to believe that organized society
and selected individuals would be uninterested in supporting
such an enormously important challenge to intellectual and
scientific understanding, if it were clearly explained.
In summary, I have attempted to discuss with you some aspects
of research in anesthesiology. A cultural perspective approach
has been used for this purpose. The objectives for the future have
been also considered and my personal and possibly biased views
have been set before you for consideration. REFERENCES
1. Barzun, Jacques. Darwin, Marx and Wagner (1949)
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